Philadelphia Gastroenterology Consultants, Ltd.

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1 Philadelphia Gastroenterology Consultants, Ltd. Date Dear An appointment has been scheduled for you to see on at. 1. PLEASE ARRIVE PROMPTLY FOR YOUR APPOINTMENT. CANCELLATIONS MUST BE MADE 24 HOURS IN ADVANCE OF YOUR APPOINTMENT OR A $25 FEE WILL BE APPLIED. 2. Please fill out the medication list by reading the labels on your prescription bottles and filling in the form, or bring the actual medication bottles if you have trouble. 3. Please bring all recent (within 6months) blood test results, x-ray results (CT scan, ultrasound, MRI, etc) or other test related to your problem with you on the day of your appointment. If you do not have these tests available at the time of your appointment, our doctors may not be able to fully evaluate you. 4. Please fill out the enclosed information sheets ahead of time and bring them with you, along with your insurance card and a form of photo I D. This will save you time from waiting to be taken into an exam room. 5. If you have HMO insurance, you must have a referral from your primary physician or you will not be able to be seen. 6. All co-pays are due at the time of your office visit. Our office reserves the right to reschedule your appointment if co-pay is not paid. 7. In the event you do not have any insurance, you will be expected to pay for your service in full at the time of your appointment. Any questions or concerns you may have about payment can be directed to the billing department before your appointment. 8. We look forward to seeing you and will do everything possible to make your visit comfortable and pleasant. PLEASE ARRIVE 30 MINUTES EARLY FOR YOUR APPOINTMENT SO THAT WE MAY COLLECT AND PROCESS ALL OF YOUR INFORMATION 700 Cottman Ave +Bldg. B + Suite 201 +Philadelphia, PA Phone: (215) Fax: (215) Website:

2 Philadelphia Gastroenterology Consultants, Ltd. PGC Endoscopy Center for Excellence, LLC 700 Cottman Avenue - Bldg 8 Suite Philadelphia, PA Phone Fax Please PRINT all information Date: Patient Information Form Last Name First Name Date of Birth Age Ml Social Security Number Street Address City State Zip Code Home Phone Cell Phone Work Phone Are you currently employed? YES NO Circle one: Sex M F Marital Status: S M D W Circle one: Ethnicity: Hispanic or Latino Not Hispanic or Latino Race: Language Local Pharmacy Local Pharmacy Phone Mail Order Pharmacy Mail Order Pharmacy Phone Emergency Contact. Phone Emergency Contact Relationship to the Patient Primary Care Provider Phone. Referring Provider Phone. Insurance Information Primary Insurance and Address. Name of Subscriber Policy ID# Group# Name of Subscriber Policy ID# Group# Reviewed for accuracy:.

3 Philadelphia Gastroenterology Consultants, Ltd. PGC Endoscopy Center for Excellence, LLC BILLING CONSENT 1 hereby accept responsibility for payment for any service(s) provided to me that is not covered by my insurance. I also accept responsibility for fees that exceed the payment made by my insurance, if the Practice/Center does not participate with my insurance. I agree to pay all co-payment, co-insurance and deductibles at the time the service is rendered. I hereby authorize release of medical information by Philadelphia Gastroenterology Consultants, Ltd and/or PGC Endoscopy Center for Excellence, LLC to my insurance Company. I hereby assign all medical and/or surgical benefits, including major medical benefits, Medicare and commercial insurance to Philadelphia Gastroenterology Consultants, Ltd. or PGC Endoscopy Center for Excellence, LLC. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. Signature of Patient or Guardian Date If Guardian, Name and Relationship to Patient CONSENT TO OBTAIN EXTERNAL PRESCRIPTION HISTORY I, whose signature appears below, authorize Philadelphia Gastroenterology Consultants, Ltd and PGC Endoscopy Center for Excellence, LLC and its Affiliated Providers to view my external prescription history via our electronic medical record system, eciinicaiworks. I understand that prescription history from multiple other unaffiliated medical providers, insurance companies, and pharmacy benefit managers may be viewable by my providers and authorized staff here, and it may include prescriptions back in time for several years. MY SIGNATURE CERTIFIES THAT I HAVE READ AND UNDERSTAND THE SCOPE OF MY CONSENT AND THAT I AUTHORIZE THIS ACCESS. Signature of Patient or Guardian Date If Guardian, Name and Relationship to Patient

4 Philadelphia Gastroenterology Consultants, Ltd. PGC Endoscopy Center for Excellence, LLC PATIENT HISTORY FORM Date: PATIENT NAME (as it appears on your insurance card) DOB Reason for your visit: Referring Provider: Primary Care Provider: Other Providers You Are Seeing: Local Pharmacy: Phone Number: Mail Order Pharmacy: Current Medications (including over-the-counter. vitamins and herbal supplements) Name Dose Frequency Name Dose Frequency

5 PATIENT NAME DOB Past Medical Illnesses D None D Alzheimer's D Anemia D Anxiety D Arthritis D Asthma D Back pain D Blood transfusion D Breast Cancer D Chronic lung disease D Cirrhosis of liver D Colitis D Colon cancer D Colon polyps D Crohn's disease D Depression D Diabetes D Diverticulitis D Diverticulosis D Emphysema D Esophageal cancer D Frequent urinary infections D Gallstones D Glaucoma D Gout D Heart attack D Heart murmur D Hepatitis DA DB DC D Hiatal hernia D High blood pressure D High cholesterol D High Triglycerides D HIV/AIDS D Irregular heart beat D Irritable bowel syndrome D Kidney disease D Kidney failure D Kidney stones D Lactose intolerance D Liver Cancer D Osteoporosis D Pancreatitis D Paralysis D Parkinson's D Pneumonia D Prostate cancer D Reflux D Rheumatic Fever D Seizures D Skin Cancer D Stroke D Tuberculosis D Thyroid disease D Ulcer D Ulcerative colitis D o D o o Allergies D None D Aspirin D Codeine D Demerol D Iodine D Morphine D Penicillin D Sulfa D Valium D Latex D 0 Previous Suraeries and Year Performed D None D Hemorrhoids D Prostate D Appendectomy D Hiatal hernia repair D Stomach D Breast biopsy D Hip replacement D Sterilization D Cardiac Bypass D Hysterectomy D Thyroid surgery D Cholecystectomy (gallbladder) D Kidney D Tonsillectomy D Colon resection D Knee surgery D Vascular surgery D Colostomy D Lung surgery D D C-section x D Mastectomy D D Groin hernia x D Obesity surgery D D Heart valve replacement/repair D Ovaries/Tubes D Past Gastrointestinal Examinations Procedure Results Date of Exam Performed by Colonoscopy Upper Endoscopy Capsule Endoscopy Sigmoidoscopy ERCP Liver biopsy

6 PATIENT NAME DOB FAMILY HISTORY Deceased Alcoholism Anemia Bleeding tendency Breast Cancer Colon Cancer Age at diagnosis Colon polyps Crohn's disease Depression Diabetes Esophagus cancer Heart problems Hepatitis High blood pressure Liver cancer Liver disease Lung cancer Lung disease Pancreatic cancer Stomach cancer Stroke Thyroid disease Ulcer Ulcerative colitis Weight problems Other cancers (type) Mother Father Brother(s) Sister(s) Children Grandparents Tobacco D I have never used tobacco products D I quit using tobacco years ago. D I smoke packs a day for years. D I use chewing tobacco Alcohol Recreational Drug Use Tattoos D Never D Rarely D Never D Currently D Professionally placed D _drinks per day D Injected D Non-professionally D In recovery D In recovery How many Social Historv D Blood transfusion When D Children How many? D Single D Married D Separated D Divorced D Widowed D Long term partner D Occupation.

7 PATIENT NAME Have you ever tested positive for MRSA? (please circle) YES NO If yes, when were you diagnosed? Review of Systems Gastrointestinal D None D Abdominal pain D Belching D Black stools D Bloating 0 Constipation 0 Changes in bowels 0 Dairy Intolerance 0 Diarrhea 0 Difficulty swallowing 0 Flatulence (gas) 0 Hemorrhoids D jaundice 0 Loss of appetite 0 Mucus in stool 0 Nausea D Pain with moving bowels 0 0 Rectal bleeding 0 D Leakage of stool 0 Vomiting 0 Stool urgency 0 General/Constitutional Pulmonary/Lung Urinary/Renal D None D None D None D Chills D Cough D Frequent urination D Fever D Shortness of breath D Blood in urine 0 Headache D Wheezing D Dialysis 0 Lightheadedness D Use of oxygen D 0 D Use ofcpap Musculoskeletal Eyes D D None D None Cardiovascular D Joint swelling D Visual Decline D None D Muscle aches D Blindness D Chest pain D Back Pain D D Shortness of breath D Ears, Nose and Throat D Ankle swelling Skin D None D D None D Post nasal drip Hematologic D Rash D Allergies D None D Bruising D Canker sores D Easy bruising DItching 0 Loss of dental enamel D History of clotting problems D D Hoarseness Female Neurologic D Hearing loss D None D None D D Heavy menses D Dizziness Endocrine D Menopause D Frequent headaches D None D D D Swollen glands Male Psychiatric 0 D None D None D Testicular/scrotal pro b. D Anxiety D D Depression D Panic attacks D Sleeping difficulty D

8 Philadelphia Gastroenterology Consultants, Ltd. PATIENT NAME: Have you undergone recent diagnostic testing? 1. CT Scan Yes No Where When 2. MRI Yes No Where When 3. Bloodwork Yes No Where When 4. Upper Gl Series Yes No Where When 5. Barium Enema Yes No Where When 6. Ultrasound Yes No Where When 7. Colonoscopy Yes No Where When 8. Upper Endoscopy (EGD) Yes No Where When 9. Stool Studies Yes No Where When 10. Other Testing Yes No Where When *New Patients* If you have answered YES to any of the above, please bring copies of ALL reports on the day of your visit. Thank you.

9 Name of Patient {Please Print) Date of Birth ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE I acknowledge that I received the Notice of Privacy Practices for Philadelphia Gastroenterology Consultants, Ltd and PGC Endoscopy Center for Excellence, LLC I request that you attempt to contact me with confidential communications about my healthcare in the following way{s): Leave messages on home answering machine? Yes o No o Phone# Leave message on voic at place of employment? Yes o No o Work# Leave messages on cell phone? Yes o No o Cell# ? Yes o No o address Discuss my healthcare with family members? {Please specify names) Additional instructions ***This request will remain in effect unless otherwise revoked writing*** Signature of Patient or Personal Representative Date Print Name of Personal Representative Relationship to Patient

10 Philadelphia Gastroenterology Consultants, Ltd. & PGC Endoscopy Center for Excellence, LLC " fo~ Chase Cancer Center Jeanes Hospital 1< 13urhalme Park Park Cheltenham e:l Our Address is 700 Cottman Ave Suite 201 in Building B Northeast "' High School t-<4e, -'~'0<:;z,.e ~. *Our parking lot and office entrance is located off of Hasbrook Avenue* t'll~'l% ~lu f'"lidiijidl,.)' El Flyers G) & Wawa 0 X 0 a. ~ l1l AutoZone 8 'i1 Wendy's Path mark ~ 'fl Chuck's Alibi & Seafood H I l 700 Cottman Avenue+ Bldg. B Suite 201 +Philadelphia, PA Phone: (215) Fax: (215) Website: pgcdocs.com

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